Difficult Diagnosis: An Interactive Session

Transcription

1 Difficult Diagnosis: An Interactive Session W A D E S M I T H, M. D. D E P T. O F N E U R O L O G Y, U C S F F E B R U A R Y 1 5, year-old man with HTN and HLD Recurrent episodes of dizziness Began 3 years ago: Sudden episodes of feeling light-headed lasting seconds Not provoked by head turning, bending forward or standing up No tinnitus or hearing loss Question 1 Which of the following statements is TRUE: a) Pure vertigo is a common presentation of TIA. b) Vertigo exacerbated by head movement is diagnostic of peripheral vertigo. c) Absence of tinnitus or hearing loss increases the chances that vertigo is of central cause. d) Older patients typically have the same prodrome as young patients when experiencing vasovagal syncope e) The dizzy patient almost kept me out of neurology a ) P u r e v e r t i g... 8% b ) V e r t i g o e x... 12% c ) A b s e n c e o f... 39% d ) O l d e r p a t i e... 13% 28% e ) T h e d i z z y p... The symptoms went away for 1 year 1 year ago the episodes returned in a different form Exclusively occurred during breakfast Now had horizontal diplopia with brief period of vertigo followed by palmar sweating 1

2 Question 2 Knowing what you know now: PMD: not orthostatic, exam normal. a) He likely has a peripheral vestibular disorder. b) Horizontal diplopia suggests he has brainstem dysfunction. c) Orthostatic hypotension is a likely cause. d) Same time phenomenon of episodes suggests a cluster migraine phenomena. e) Sweating is likely due to systemic hypotension 68% 13% 12% Cardiologist: normal exam, Holter showed intermittent a-fib, rate 180 Started metoprolol 25 BID, rate then controlled Patient had more frequent symptoms 4% 4% a ) H e l i k e l y h... b ) H o r i z o n t a l... c ) O r t h o s t a t i c... d ) S a m e t i m e p... e ) S w e a t i n g i s... Question 3 Which are the following is TRUE:. a) Patients with intermittent a-fib typically develop dizziness when tachycardic 2. b) Beta-blockers are known to exacerbate vasovagal syncope. c) His symptoms are worse because beta-blockers can worsen migraine variants 4. d) His symptoms are likely not related to the atrial fibrillation. e) He is likely having intermittent episodes of painfree angina and cardiac pump failure a ) P a t i e n t s w i t h i n t e r m i... 17% b ) B e t a - b l o c k e r s a r e k n o.. 25% c ) H i s s y m p t o m s a r e w o r.. 3% d ) H i s s y m p t o m s a r e l i k e.. 49% e ) H e i s l i k e l y h a v i n g i n t... 6% The spells are more frequent He becomes less responsive during the spells One episode of frank syncope, falling forward into his breakfast Echo LVEF 55%, valves normal; treadmill negative, Duplex normal, vertebrals antegrade EEG normal, MRI of brain normal 2

3 Meds: Lisinopril 10 mg daily Atorvastatin 20 mg daily Metoprolol 25 twice daily Aspirin 81 mg daily Further questioning: He recalls the syncopal spell Same prodrome, then quadriplegic, unable to speak Able to move when his wife shook him Question 4 Which of the following would most likely elucidate the cause of his spells: a) Tilt-table test. b) Ambulatory blood pressure monitoring. c) Intracranial CTA. d) Electronystagmyography. e) Blood pressure in each arm 58% 12% 13% 10% 7% a ) T i l t - t a b l e... b ) A m b u l a t o r y... c ) I n t r a c r a n i a... d ) E l e c t r o n y s t... e ) B l o o d p r e s s... 3

4 Vertebrobasilar Insufficiency Postprandial Hypotension Very uncommon disease Bow hunter syncope, beauty parlor syndrome Flow related TIAs Subclavian steal Intracranial atherosclerosis Rarely atherosclerosis below C1 Verebrals usually reconstitute from muscular branches Arterial dissection Low cardiac output plus vertebral or basilar stenosis Common disease (Luciano et al, 2010) 25-38% of elderly patients Can be early manifestation of Parkinson s disease or MSA Caused by gut steal Measure BP during a meal; drop in > 20 mmhg systolic is diagnostic (Zanasi et al, 2012) Morning antihypertensive meds can exacerbate Our Patient BP pre breakfast was 122/78; following breakfast 98/62 No clinical signs of Parkinson's disease or MSA Not orthostatic on repeat testing Angioplasty of the vertebral stenosis was undertaken 4

5 Carries substantial risk of stroke (Chimowitz, 2011) May have selective benefit in patients with flow restrictive lesions rather than artery-artery stroke Most common stroke is a penetrator syndrome (Fiorella, 2012) Treatment of intracranial atherosclerosis Statin (Crestor was used in SAMMPRIS) Antihypertensives ASA mg or clopidogrel 75 mg Control of diabetes, exercise, weight loss Intracranial stenting/angioplasty considered only for refractory cases 5